Hemorrhage. Under ordinary conditions, a patient may lose as much as 500 cubic centimetres of blood during or immediately after labor, without serious results, but a loss of 600 cubic centimetres or more is regarded as a hemorrhage and as requiring speedy attention.
According to Dr. Williams, severe hemorrhage occurs only once in every few hundred labors, and with proper treatment, should not result fatally in more than one out of every 2000 or 2500 cases.
The severe hemorrhage due to a partially separated placenta occurs during the third stage of labor and was discussed in that connection. As the danger of hemorrhage, after labor is completed, is greatest during that critical hour immediately following, it is practically routine the country over to watch the patient closely during this period, both for the sake of preventing bleeding and detecting its early evidence, should hemorrhage occur, thus making prompt treatment possible.
The causes of post-partum hemorrhage are: Deep cervical tears, retained portions of the placenta, and atony of the uterus.
The treatment of hemorrhage due to tears of the generative tract is suturing the torn edges.
Since the retention of even a small piece of placental tissue will prevent the uterus from contracting firmly, the treatment of hemorrhage from this cause is immediate removal of the retained fragment. It is to obviate this occurrence that the placenta is carefully inspected after its expulsion. If it is not intact, the obstetrician may introduce his finger and remove the retained portion, thus making it possible for the uterus to contract properly and close off the open blood vessels.
Atony, or impaired tone of the uterine muscles, may result in hemorrhage because of failure of the muscle fibres to constrict the vessels. Quite evidently, the first step toward controlling hemorrhage from this cause is to stimulate the muscles to contract; this is done by means of massage and the administration of pituitrin and ergot. Elevation of the foot of the bed and application of ice-bag to the abdomen are also employed.
In severe cases, the doctor may give an intra-uterine douche of hot, sterile salt solution and if this fails he may pack the uterus tightly with sterile gauze. The douche and pack represent operative maneuvers and, therefore, are never to be undertaken by the nurse. Her assistance is important, however, as strictest asepsis is imperative and she will have to prepare the patient and the necessary articles with the greatest care.
Should bleeding become profuse during the doctor’s absence the nurse must stay with the patient and massage the fundus and have some one else elevate the foot of the bed on the seat of a straight chair or upon firm blocks and summon the doctor. In anticipation of such an emergency the nurse must always have an understanding with the doctor about the administration of pituitrin and ergot. If there has been no understanding, and the doctor is delayed or the bleeding becomes alarmingly profuse, the nurse will usually be upheld if she gives 1 cubic centimetre of pituitrin, hypodermically and a dram of ergot by mouth.
It is, of course, definitely understood that nurses do not give medicines without orders, but a single dose of pituitrin and ergot upon the occurrence of a profuse hemorrhage can scarcely do harm and may actually save the patient’s life. Such a situation is an emergency fortunately a rare one, and the nurse will have to be quick-witted and use the best judgment she is capable of.